Circles of Care
Health and Safety Plan
Circles of Care
Health and Safety Plan
Table of Contents
I.
Overview ………………………………………………………………………………….……………….. 3
II.
Maintaining a Healthy and Safe Work Environment ……………………………….…….. 4
A. Fire Safety ……………………………………………………………………………………….. 4
B. Medical Emergencies ……………………………………………………………………..… 5
C. Bomb Threats …………………………………………………………………………….….... 5
D. Workplace Violence …………………………………………………….….………………... 6
E. Natural Disasters/Severe Weather Events ………………………….….…………… 7
F. Infection Prevention and Control ………………………………….…………………... 9
G. Emergency Procedure Testing and Facility Inspections ……………………… 11
III.
Maintaining Out-of-Office Health and Safety …………………………….……………….. 11
A. Safe Driving Practices and Travel …..……………………………….………….…….. 11
B. Transporting Clients …………………………………………………..…………….…….. 13
C. Home-based Offices ………………………………………………………….……………. 13
IV.
Reporting and Documenting Serious Incidents …………………………………………... 14
V.
Employee Training ……………………………………………………………………………………. 15
VI.
Appendices ………………………………………………………………………………………………. 16
A. Office Evacuation Plans
B. Emergency Phone Numbers & Emergency Codes
C. Circles of Care Safety Check Form
D. Responding to Bomb Threat Checklist
E. Circles of Care Safety Drill Form
F. Circles of Care Health and Safety Checklist
G. Circles of Care Transportation Emergency Procedures
H. Circles of Care Employee Incident Report
Health and Safety Plan
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Circles of Care
Health and Safety Plan
I.
Overview
A.
Intent Statement
Circles of Care, as an agency, values all employees and is committed to
maintaining the health and safety of all staff as a priority. This commitment to
health and safety is fulfilled through the active participation of all staff, and is
extended to all persons served, personnel, and other stake holders.
B.
Policy Statement
The Circles of Care Health and Safety Plan is designed to outline the protocols in
place to maintain a safe and injury/illness free work environment for each
program area. Accident prevention is a responsibility of and concern for all
employees. This includes the safety and well being of employees, subcontractors,
and persons served. Compliance with the Health and Safety Plan is mandatory
for all employees of the company. It is the aim of Circles of Care to prevent
accidents, injuries and illness resulting from all foreseeable workplace hazards
and risks and to respond rapidly and appropriately when these occur.
C.
Applicability
The Circles of Care Health and Safety Plan applies to all employees of Circles of
Care, regardless of position within the company. The health and safety protocols
contained herein apply to all subcontractors, interns, and volunteers. Every
employee is expected to comply with the Circles of Care Health and Safety Plan.
D.
Enforcement
The authorization and responsibility for enforcement of the Health and Safety
Plan has been given primarily to the Safety Officer/Human Resources Director.
The Program Director for each program area will share in this responsibility as
well. The Safety Officer and Program Directors will meet at least annually to
evaluate all areas of safety and make recommendations for changes as necessary
to the State Administrator and Executive Director.
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II.
Maintaining a Healthy and Safe Work Environment
A.
Fire Safety
Employees should be knowledgeable in fire prevention and emergency response
in the work place. Major causes of fires in the work place include arson, smoking
materials, wiring, and appliances. It is important to keep doors locked after
business hours, keep areas near doorways and around building clear, and pay
attention to housekeeping within the building. Smoking is not allowed in any
Circles of Care offices/buildings. In designated smoking areas (located outside of
the building, away from entrances), large, non-tip ashtrays should be used.
Outlets should not be overloaded. Any broken or cracked electrical cords should
be replaced immediately. Become familiar with the facility’s fire and life safety
systems. Know what types of fire safety systems the building has, as well as their
location –and how to use them (i.e., Fire extinguishers, Smoke detectors,
Sprinklers, Alarms, Evacuation Plans).
Fire Response Plan
If the fire/smoke alarm sounds, or a fire is suspected:
 Dial 911 immediately.
 Exit the building according to evacuation plan (close doors when exiting to
help limit spread of smoke and fire). Never use elevators during a fire
emergency. Proceed to the identified employee meeting place.
If an intercom system is available, Code Red should be announced; Skype or
other instant messaging systems may also be utilized to announce the fire
emergency.
Fire Extinguisher: In the event of a smaller, contained fire, call 911 and then
utilize the fire extinguisher. If you are unable to extinguish the fire, leave and
close the door behind you.
Evacuation Plans: Evacuation plans are kept on file and posted in each program
office, in all common areas. Evacuation plans identify location of fire
extinguishers and where everyone should meet so that each employee may be
accounted for. The meeting location should be far enough from the building to
provide safety for the evacuees, but also to allow for emergency responder access.
See Appendix A for each office evacuation plan.
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B.
Medical Emergencies
It is important to anticipate and plan for situations that may require on-site
emergency medical care. Regardless of the type of emergency, medical
procedures focus on three basic steps, which the American Red Cross identifies as
Check-Call-Care.
The first step is to secure the scene and check the injured person.
 If the situation is serious or life-threatening, the next step is to call
emergency 911.
 Then, begin providing emergency life-support (CPR) and/or First-Aid
services.

If an intercom system is available Code Blue should be announced; Skype or
other instant messaging systems may also be utilized to announce the medical
emergency.
All Circles of Care employees must be trained in First-Aid and CPR. All Circles of
Care program offices are equipped with First-Aid kits. Circles of Care Evacuation
plans all indicate where First-Aid kits are located within the office. Direct care
employees also have First-Aid kits in their vehicles.
First-Aid kits must be inventoried on a quarterly basis, or after each medical
emergency to ensure it is properly stocked. The inventory/stock will be
documented on the Circles of Care Safety Check Form and submitted to the
Safety Officer. If additional supplies are required, a purchase request will
accompany the Safety Check Form.
C.
Bomb Threats
Bomb threats are made to warn people to leave a location where an explosive
device may have been placed. Another reason for making a bomb threat is to
cause alarm, panic, and get attention and response. Bomb threats are usually
received by telephone. All personnel must be instructed in responding to bomb
threats, especially those at the telephone switchboard.
It is always desirable that more than one person listen in on the call if possible. If
possible, the person receiving the threat should notify other employees of the
active threat. If an intercom system is available Code Yellow should be
announced; Skype or other instant messaging systems may also be utilized to
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announce the bomb threat. The person receiving a bomb threat should remain
calm and attempt to obtain as much information as possible from the caller
(Appendix D Bomb Threat Call Checklist).
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Keep the caller on the line as long as possible
Record/document every word spoken by the person if possible
If the caller does not indicate the location of the bomb, ask for this
information
Pay particular attention to background noises which may give a clue as to
the location of the caller
Listen closely to the voice (male/female), accents, and speech
impediments
Immediately after the caller hangs up, call 911 and evacuate the building,
according to identified evacuation plan
Report the threat to immediate supervisor and Safety Officer
Each office should have a copy of the Bomb Threat Call Checklist accessible in
any area where telephones are answered. The checklist should be used, if
possible, to document the elements of the threat. A copy of the checklist should
be provided to responding police officers, as well as to the Circles of Care Safety
Officer.
D.
Work-place Violence
Work-place violence is any intentional act that inflicts, attempts to inflict, or
threatens to inflict bodily hurt on another person or property, whether
committed by a Circles of Care employee or by anyone else and which occurs in a
Circles of Care program office or while an employee is engaged in Circles of Care
business.
The following control measures are reliable and will provide protection for
employees and assist in the prevention of work-related violence:
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The office building is secure and maintained
Security measures are used (cameras) where available
Internal and external lighting is installed to assist visibility
Furniture and partitions are arranged to allow good visibility of service
areas and avoid restrictive movement
There is no public access to the premises when people work at night
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Supervisors are made aware of staff general whereabouts when making
home visits or engaging in other work-related tasks within the community
(transporting children to family visits, attending court hearings, etc.)
The use or sale of alcohol, illegal, or non-prescribed drugs , or reporting
for work under the influence of such substances is prohibited
Displaying behavior that could endanger oneself or a fellow employee such
as fighting, engaging in horseplay, and disorderly or disruptive behavior is
prohibited
All staff is trained in Emergency Behavior Intervention, which includes deescalation techniques that may be used with any age group
Supervisors should be watchful for problematic behaviors of employees
(i.e., increasing belligerence, threats, apparent obsession with coworker,
outbursts of anger, noticeable changes in behavior)
If violence occurs, employees should:
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Dial 911
Evacuate the area immediately
Help others evacuate/escape if possible
Prevent others from entering the area
If unable to evacuate, find a safe place out of the violent person’s view
Skype or other instant messaging systems may also be utilized to announce the
threat and instruct employees to evacuate the building, Code Gray.
When interacting with the violent or threatening person:
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E.
Use calm verbal and non-verbal communication
Use verbal de-escalation and distraction techniques
Ask the aggressor to leave the premises
Retreat to a safe location if possible and call 911
Natural Disasters/Severe Weather Events
A natural disaster is a major adverse event resulting from natural processes;
examples include hurricanes, tornadoes, floods, severe thunderstorms, and
winter storms. Being prepared and acting quickly is critical during the threat of
severe weather.
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Hurricanes are strong storms that can be life-threatening as well as cause serious
threats such as flooding, storm surge, high winds and tornadoes.
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Listen to area radio and television stations for critical information from
the National Weather Service
Secure windows and doors; contact maintenance or landlords to assist
Be prepared to evacuate
Unplug, elevate, and secure all computers and other electrical devices
Elevate all filing cabinets and/or move books, binders, paper items to
higher areas of the offices
Severe thunderstorms may produce hail at least 1 inch in diameter and/or have
wind gusts of at least 58 miles per hour. Every thunderstorm produces lighting
and often has heavy rain that can cause flooding. High winds can cause
structural damage, blow down trees and utility poles, and cause widespread
power outages
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Listen to area radio and television stations for critical information from
the National Weather Service
Stay away from windows, skylights, and glass doors that could be broken
by strong winds or hail
A tornado is a violently rotating column of air extending from the base of a
thunderstorm down to the ground. Although severe tornadoes are more common
in Plains States, tornadoes have been reported in every state.
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During any storm, listen to area radio and television stations for critical
information from the National Weather Service
If a tornado is approaching move to a small, interior room or hallway, on
the lowest floor with no windows
If an intercom system is available Code Orange should be announced;
Skype or other instant messaging systems may also be utilized to
announce the tornado warning/threat.
Floods are among the most frequent natural disasters. Conditions that cause
floods include heavy or steady rain for several hours or days that saturate the
ground.
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Listen to area radio and television stations for possible flood warnings and
reports of flooding in progress or other critical information from the
National Weather Service
Be prepared to evacuate
Unplug, elevate, and secure all computers and other electrical devices;
cover in large trash bags
Elevate all filing cabinets and/or move books, binders, paper items to
higher areas of the offices
Stay away from flood waters, walking or driving
The following steps will be taken to secure records during a natural
disaster/severe weather event or in the event of other critical equipment failure:
 The Executive Director and IT Department will ensure that a back up is
done of its centralized database program. Circles Backup Disaster
Recovery Server (DHCP) is a Microsoft Windows 2008 R2 Standard,
member server of the domain that asks a storage repository for all Shadow
Protect backups of the other servers in the domain. It runs Image
Manager for compression and management of the backup image files and
RTS backup software for transfer of the files to our offsite backup data
store. (Refer to COC Technology Plan for more information)
 Paper records will be secured and will be attempted to be protected as
much as possible based on the type of disaster
F.
Infection Prevention and Control
Infectious Diseases (also called communicable diseases) kill more people
worldwide than any other single cause. Infectious diseases are caused by germs.
Germs are tiny living things that are found everywhere - in air, soil and water.
You can get infected by touching, eating, drinking or breathing something that
contains a germ. Germs can also spread through animal and insect bites, kissing
and sexual contact. Vaccines, proper hand washing and medicines can help
prevent infections.
Circles of Care recognizes the seriousness of infectious diseases and requires
employees participate in training regarding the prevention of the spread of
communicable diseases. All employees are also required to have a Tuberculosis
(TB) screening when hired. The following general practices are encouraged to
help stop the spread of germs in the work place:
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When you cough or sneeze, you send tiny germ-filled droplets into the air.
Colds and flu usually spread that way. You can help stop the spread of
germs by:
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Covering your mouth and nose when you sneeze or cough. Sneeze or
cough into your elbow, not your hands.
Cleaning your hands often - always before you eat or prepare food, and
after you use the bathroom or change a diaper
Avoiding touching your eyes, nose or mouth
Hand washing is one of the most effective and most overlooked ways to
stop disease. Soap and water work well to kill germs. Wash for at least 20
seconds and rub your hands briskly. Disposable hand wipes or gel
sanitizers also work well.
The following are recommended hygienic practices for care providers and staff
caring for people with infections disease.
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Spills of semen, blood, bloody saliva, urine, feces, or vomit on surfaces
such as floors, bathtubs, etc. should be cleaned with a solution of ten
(10) parts water to one (1) part bleach. The towel or cloth used for the
cleanup shall be placed in a sealed plastic bag and put outside in a
trash can. Disposable rubber gloves shall be used during the cleaning
of any and all bodily fluid spills.
Clothes that have been soiled with fluids shall be washed separately
from other clothes with ten (10) part water to one (1) part bleach
mixture.
Bloody body fluids found in or on bottles, dishes, cups, or eating
utensils shall be washed separately either by hand or in the dishwasher
with hot soapy water.
Disposable soiled diapers should be placed in a sealed plastic bag and
placed in a trash can outside.
If a child with an infectious disease bites someone and draws blood, the
area should immediately be washed with hot water and soap and
reported to a doctor.
Care providers and staff are encouraged to assure that immunizations
are up to date for childhood diseases such as mumps, Rubella, etc. as
determined by their physician.
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G.
Emergency Procedure Testing and Facility Inspections
Circles of Care employees are trained regarding the Health and Safety Plan
during new employee orientation and annually thereafter.
Emergency
procedures must be reviewed with staff and practiced periodically to ensure
comprehension and ability. Most office emergencies require evacuation as some
part of the identified response.
Evacuation Drills: Unannounced evacuation drills will be held in an effort to
practice the evacuation plan. This is to occur on a biannual basis or as often as
the Safety Officer deems appropriate. These drills will be monitored and used as
a training tool. Any concerns noticed by the monitor or staff being evacuated will
be discussed and addressed as necessary. Evacuation drills and subsequent
observations/concerns will be documented by the Safety Officer on the Circles of
Care Safety Drill form and submitted to the State Administrator and Executive
Director for review. See Appendix E.
Other Safety Drills: The Safety Officer will instruct Program Directors in
implementing additional unannounced drills, such as bomb threats, medical
emergencies, and violence. The Program Director will announce the drill and
explain the scenario to be simulated. Employees are to react as if it is an actual
emergency and follow procedures. The Program Director will observe the
response and document it accordingly. Documentation will be completed on the
Circles of Care Safety Drill form and submitted and reviewed by the Safety
Officer.
Facility Inspections: Annual facility inspections will be completed by a qualified
external authority (fire/health inspector). Fire extinguishers will be inspected for
required maintenance or service, annually by an approved external service
provider. Annual inspections and any subsequent compliance inspections will be
submitted to the Safety Officer. Biannual internal health and safety inspections
will be completed by Program Directors. These inspections will be documented
on the following forms: Circles of Care Safety Check Form and the Circles of Care
Health and Safety Checklist. See Appendix C.
III.
Maintaining Out-of-Office Health and Safety
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A.
Safe Driving and Travel Practices
Travel and field work is required and a core component of most employee roles
within Circles of Care. Primarily, Case Managers and Foster Home Developers
are required to travel (short distances and long trips) on a routine basis, while
completing general job-related responsibilities. In an effort to keep employees
safe, Circles of Care implements the following requirements:
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All employees must complete Transportation Safety training.
Employees who must travel as part of their job requirements, must have a
valid driver’s license, have reliable transportation, maintain automobile
liability insurance, and maintain vehicle maintenance (proof of each must
remain on file with the Human Resources Director/Safety Officer).
Circles of Care encourages the following safe driving practices:
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Use a seat belt at all times –driver and passenger(s)
Be well-rested before driving
Avoid taking medications that make you drowsy
Set a realistic goal for the number of miles you can drive safely each day
If you are impaired in any way, do not drive
Avoid distractions, such as adjusting the radio, eating or drinking, or
talking on the phone
Stay alert to the environment and situation requiring quick action
When traveling long distances, stop and take a break every two hours
Keep your cool in traffic
Be patient and courteous to other drivers
Do not take other drivers’ actions personally
Reduce stress by planning your route ahead of time
Have a good knowledge of the road traffic laws and abide by them at all
times
Ensure your supervisor or a coworker knows your general daily itinerary
Other long-distance travel safety tips:
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Leave valuables home whenever possible, and never leave baggage or
personal items unattended
Know your travel route and make sure vehicle is in good condition
Keep doors locked while driving; lock doors when leaving your vehicle
Keep doors locked securely when staying overnight in a hotel
Identify anyone who knocks on door prior to allowing access to hotel room
When walking in unfamiliar places, stay with the crowd on well-lit streets
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B.
Walk briskly and confidently and keep alert to surroundings
Ensure your supervisor or a coworker knows your travel and daily
itinerary
Transporting Clients
It is often required and/or requested that Circles of Care employees assist in
transporting clients. This is especially true for Case Managers and Human
Service Technicians. In an effort to keep employees and clients safe, Circles of
Care implements the following requirements:
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C.
All employees must complete Transportation Safety training.
Employees transport clients, must have a valid driver’s license, have
reliable transportation, maintain automobile liability insurance, and
maintain vehicle maintenance (proof of each must remain on file with the
Human Resources Director/Safety Officer).
Circles of Care will conduct biennial checks of the employee’s driving
record.
Vehicles used to transport clients must have working safety belts; if
transporting young children, appropriate child restraints must be used.
Vehicles used to transport clients must have a fully stocked first-aid kit.
When transporting clients, the driver must have a general awareness of the
child and his or her circumstances –including medical conditions/needs,
behavior issues, and safety plans.
When transporting clients, employees must ensure they have their cell
phone available; the vehicle should be safely parked before using the
phone.
Under no circumstances may a client be left unattended in a vehicle.
Vehicles used to transport clients must have emergency procedures
available. See Appendix G.
In the event of an emergency the Circles of Care Transportation
Emergency Procedures must be followed. See Appendix G.
Home-Based Staff
Circles of Care allows Case Managers to work from a home based office. In an
effort to ensure the health and safety of home-based staff, the following health
and safety parameters are encouraged:
Setting up your home office:
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Place your computer on a standard-height desk or workstation, preferably
one that’s recommended for computers. Choose a standard, five-legged
office chair. These chairs minimize the risk of injury over time by
encouraging good posture and back position. In addition, their stability
decreases the likelihood of injury from falling over backward. Work in an
area with proper lighting—bright enough to read your accompanying
documents, but not more than 10 times brighter than the monitor.
Preventing fire hazards:
Don’t overload electrical circuits and extension cords. Have a fire
extinguisher handy. Be careful not to spill liquids on your computer,
monitor, printer, etc. Don’t get distracted by doing multiple tasks that
involve fire risks, especially cooking in the kitchen while working. Don’t
smoke. A stray cigarette or match can ignite paper, chemicals, or electrical
equipment. Have a fire escape route planned—a good idea for any home.
Make sure that your office set-up doesn’t hinder escape. For instance,
don’t place a large, difficult-to-move cabinet in front of the windows. As
with the rest of your house or apartment, use common sense when dealing
with fire hazards.
IV.
Reporting and Documenting Serious Incidents
A.
Reporting Serious Incidents
A serious incident is an unplanned or undesired event that adversely affects the
company’s work operations. Such incidents include but are not limited to: fires,
work-related injuries or other medical emergencies, bomb threats, threats of
violence, damage or injury as a result of a natural disaster or severe weather
event, automobile accidents, use of emergency behavior interventions,
abuse/neglect of a child, and use/possession of alcohol, illegal substances or
weapons on company premises.
Reporting serious incidents allows for proper investigation as warranted, but also
to identify causes, trends, and areas that require performance improvement. All
serious incidents must be reported to the Program Director immediately. The
Program Director will then notify the Safety Officer and ensure the proper
documentation of the incident.
B.
Documenting Serious Incidents
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All serious incidents will be documented on the Circles of Care Employee
Incident Report (Appendix H). The report will be completed by the employee
involved or the Program Director. The incident report will then be submitted to
the Safety Officer who will review and staff with the State Administrator and
Executive Director to determine corrective actions or plans.
The Safety Officer will keep on file all serious incidents and create an annual
report analyzing all serious incidents to identify any trends, pending corrective
actions (to include employee training), and recommendations for prevention of
reoccurrences. The annual report will be submitted to the State Administrator
and Executive Director.
C.
TDFPS Requirements
Circles of Care must report all serious incidents (a non-routine occurrence that
has or may have dangerous or significant consequences on the care, supervision,
and/or treatment of a child) to Licensing, as per the Texas Department of Family
and Protective Services Minimum Standards for Child-Placing Agencies
Subchapter D §749.501-515.
V.
Employee Training
Circles of Care employees are trained in health and safety procedures. Employees must
participate in the following trainings upon hire and annually thereafter, unless
otherwise indicated:
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Circles of Care Health and Safety Plan Training
Emergency Behavior Intervention (PAPH)
First Aid and CPR (typically good for two years)
Psychotropic Medication and Medication Administration
Transportation Training
On-going training activities include the use of unannounced evacuation drills and other
safety drills. Additional training may be required as necessary.
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Appendix A
Circles of Care Office Evacuation Plans
Circles of Care – Corporate (1)
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Circles of Care – Corporate (2)
5333 Everhart, Suite 150B
Corpus Christi, Texas 78411
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Circles of Care – RGV
612 W. Nolana Suite 510
McAllen, TX 78504
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Circles of Care – Houston
340 North Sam Houston Pkwy East Suite 150
Houston, Texas 77060
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Circles of Care – Central Texas
805 N. Main Street
Salado, TX 76571
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Circles of Care – Dallas
9535 Forrest Lane #101A
Dallas, TX 75243
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Circles of Care – Laredo
709 Alta Vista Dr. #103
Laredo, TX 78041
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Appendix B
Circles of Care Emergency Phone Numbers
Name
Office Number
Cell Number
Carrie Mata –Safety Officer
361-852-3812
361-876-5380
Lisa Edwards –Executive Director
361-852-3812
361-728-4787
Mike Esquivel –State Administrator
361-852-3812
361-585-5500
Kirsten Wigley –Program Director
254-947-0030
254-780-7680
Summer Solomon –Program Director
956-688-6948
361-219-4782
Henry Martinez –Program Director
361-852-3812
361-765-1254
Cynthia Lee –Program Director
281-260-6814
832-696-3850
Circles of Care Emergency Codes
Nature of Emergency
Code
Fire
Code Red
Medical
Code Blue
Threat of Violence
Code Gray
Tornado
Code Orange
Bomb Threat
Code Yellow
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Appendix C
Circles of Care Safety Check Form
Date of check: _______________________ Done by:___________________________________
Office or facility location:_________________________________________________________
Smoke Alarm:
Working/ in good order
Not working/ not in good order
If not in working order document below how remedied and date.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Fire Extinguisher:
Passed
not passed
If not passed, document when serviced.
______________________________________________________________________________
______________________________________________________________________________
First Aid Kit:
present and supplies adequate
Missing or supplies low
If not adequate, document how remedied and date
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Office/facility:
No visible or apparent hazards
Visible or apparent hazards
Refer to attached COC Work-Place Health and Safety Checklist
If any visible or apparent hazards document what they are, how they were remedies and date.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Appendix D
Circles of Care Bomb Threat Call Checklist
Name used if applicable: _________________________________________
Exact wording of threat Caller: _____________________________________
____________________________________________________________
____________________________________________________________
When is the device going to explode? ________________________________
Where is the device (bomb) now? Building ________ Room _______________
What does it look like? ___________________________________________
What will cause it to explode? _____________________________________
Why? _______________________________________________________
When did you plant the bomb? ____________________________________
BACKGROUND OF THE BOMB THREAT CALLER:
Bomb Threat Caller ID if available: __________________________________
Voice: Male ________ Female _________ Accent ______________________
Nationality (if possible): ________________ Intoxicated: ________________
Speech Obstruction: ___________________ Age (approximately): _________
Background Noise: ______________________________________________
Familiar with the building: _________________________________________
If Mentioned Personnel Name: ______________________________________
Other: _______________________________________________________
*****************************************************************
Employee receiving the call: ________________________ Date: ____________
Program Area: __________________________________
Program Director: _______________________________ Date: ____________
Safety Officer: __________________________________ Date: ____________
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Appendix E
Circles of Care Safety Drill Form
Date: ___________________
Type of Incident Drill:  Fire  Bomb Threat  Workplace Violence  Tornado
 Other:________________________
Observations/Notes:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Staffing/Discussion/Feedback to staff:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Staff Signature: __________________________
Staff Signature: __________________________
Staff Signature: __________________________
Staff Signature: __________________________
Staff Signature: __________________________
Staff Signature: __________________________
Staff Signature: __________________________
Staff Signature: __________________________
Staff Signature: __________________________
Staff Signature: __________________________
Safety Officer Signature: __________________________ Date: ____________
Health and Safety Plan
Page 26
Appendix F
Circles of Care Health and Safety Checklist
Program Office:_________________________________ Date: _____________
Yes
No
NA
1. There are at least two unblocked exits to the outside from the building
(can include windows)
2. Electrical wiring system appears in good repair
3. Electrical outlets in common areas have child-proof covers
4. Fuses or circuit breakers in fuse box appear in good operating condition
5. Cords for electrical appliances and lighting fixtures appear in good
operating condition
6. Extension cords and surge protectors are used properly
7. There is an operable dry chemical fire extinguisher available for use in
the office
8. Fire extinguisher is serviced after each use and checked for proper
weight at least once a year
9. An evacuation plan is posted in common areas
10. Evacuation drills are practiced regularly
11. There is a method available to alert staff to a fire
12. The flooring in the office clean, and free of debris
13. Stairways and aisles are clean, unblocked and well-lit
14. Furniture and equipment is safe and well maintained
15. Fully-stocked First-Aid kit is located in the office
16. All materials and supplies are stored safely
17. All cleaning supplies are properly stored
18. Trash is cleared from the office; trash does not overflow any receptacles
19. Kitchen areas are kept clean and in order
20. Restrooms are kept clean, with available hand soap and towels
Comments/Concerns: __________________________________________________
__________________________________________________________________
Inspection Completed By:______________________________ Date: _____________
Re-Inspection Due Date: ______________________________
Submitted to COC Safety Officer By: _______________________ Date: _____________
Health and Safety Plan
Page 27
Appendix G
Circles of Care Transportation Emergency Procedures
Personal Safety Guidelines when transporting children:





Ensure vehicle is in good repair, properly fueled, has written emergency procedures and
emergency numbers, and has a fully-stocked First-Aid kit.
All staff and clients must wear seatbelts when transporting or being transported by
agency personnel.
Drivers must not drive and talk on their cell phones or use other electronic devices while
driving; pull off the road and make the call once the car is parked.
Proper child restraints must be appropriately utilized, as per Texas laws.
Any time a staff member feels unsafe with a client in their car, they should immediately
contact their Program Director for assistance.
In case of an accident:




Call 911 immediately; note the officer’s name and ask how to obtain a copy of the police
report
Record information from all parties involved (name, address, phone number, name of
insurance and policy number, type of vehicle, license number, witness name and
numbers)
Contact Program Director to report the incident and request support if needed
A Circles of Care Employee Incident Report must be completed to document the
accident. If a child or youth is injured in the accident, ensure appropriate medical
attention is provided. Complete a Circles of Care Serious Incident Report and follow
appropriate reporting protocols.
In the event of a client emergency (posing a risk to self or others):




Pull the vehicle to a safe location when it is safe to do so and assess the situation
Make efforts to de-escalate the client
Call 911 if necessary
If a wound has been inflicted, assess the severity and apply emergency first aid, if
necessary or possible.
Emergency phone numbers: 911
Carrie Mata, Safety Officer
Lisa Edwards, Executive Director
Mike Esquivel, State Administrator
Kirsten Wigley, Program Director
Summer Solomon, Program Director
Henry Martinez, Program Director
Cynthia Lee, Program Director
Health and Safety Plan
361-852-3812
361-852-3812
361-852-3812
254-947-0030
956-688-6948
361-852-3812
281-260-6814
361-876-5380
361-728-4787
361-585-5500
254-780-7680
361-219-4782
361-765-1254
832-696-3850
Page 28
Appendix H
Circles of Care Employee Incident Report
Date
_____________________
Employee
Name __________________
Title/position__________________
Supervisor
Name ___________________
Title/position __________________
Incident
Date _________________________________________________________
Time _________________________________________________________
Location ______________________________________________________
Description of incident
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Employee explanation
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Witnesses
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Action to be taken
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________
______________________________
Employee
Supervisor
Date
Date
______________________________
Safety Officer
Health and Safety Plan
Date
Page 29